Instrumentation and methods for inserting an intervertebral disc prosthesis

ABSTRACT

Embodiments of instrumentation and methods are provided for the insertion of intervertebral disc prosthesis. The instrumentation of the embodiments comprises a guide comprising at least two lateral faces, at least one upper plate, at least one lower plate, at least one retainer, a cage defining an insertion axis for the prosthesis, and an angle adjuster adapted to adjust an angle formed by the insertion axis and an antero-posterior sagittal axis; and at least one separator sized to maintain a gap between the upper vertebra and the lower vertebra. Methods for implanting a prosthesis using the disclosed instrumentation comprise implanting a pin in the median sagittal axis of a vertebrae; measuring the dimensions of the intervertebral space; choosing the prosthesis; choosing the guide; adjusting the angle adjuster; positioning the guide adjacent to the intervertebral space; inserting the prosthesis into the guide; and inserting the prosthesis into the intervertebral space.

CROSS REFERENCE TO RELATED APPLICATIONS

This application is a continuation of U.S. patent application Ser. No.11/180,868, filed Jul. 13, 2005 now U.S. Pat. No. 7,632,282, whichclaims priority under 35 U.S.C. 119 to French Patent Application No. 0506652, filed in FRANCE on Jun. 29, 2005.

TECHNICAL FIELD

The present invention relates to instrumentation for insertingintervertebral disc prostheses.

BACKGROUND

Various types of instruments for inserting intervertebral discprostheses are known, such as those disclosed in the French patentapplication FR0405899000 filed by the applicant. These instruments onlyallow insertion by anterior access, along the antero-posterior axis ofthe prosthesis. Preparation of the vertebrae between which theprosthesis is to be implanted by this type of instrumentation thereforerequires opening the tissue covering these vertebrae and pushing asidethe blood vessels on the anterior face of the spinal column, whichgenerates a risk for the patient.

The embodiments disclosed herein provide instrumentation and methodsthat allow insertion of a prosthesis between the vertebrae, laterally orobliquely, while appropriately positioning the prosthesis in relation tothe sagittal plane and the coronal plane.

Embodiments of instrumentation for the insertion of intervertebral discprosthesis between vertebrae in accordance with the present inventioncomprise a guide and at least one separator. In preferred embodiments,the guide has at least two lateral faces, at least one upper plate, atleast one lower plate, at least one retainer, a cage defining aninsertion axis for the intervertebral disc prosthesis and having openposterior and anterior faces, and an angle adjuster adapted to adjustthe angle formed by the insertion axis and an antero-posterior mediansagittal axis of the vertebrae. The separators are sized to maintain agap between the upper vertebra and the lower vertebra that is sufficientfor insertion of the intervertebral disc prosthesis through the guideinto the intervertebral space. For the disclosed embodiments, during theinsertion of the intervertebral disc prosthesis the upper plate isdisposed proximal to a plane substantially coincident with the lowersurface of the upper vertebra, and the lower plate is disposed proximalto a plane substantially coincident with the upper surface of the lowervertebra. The upper plate and the lower plate are separated by adistance approximately equal to the height of the intervertebral discprosthesis. The angle adjuster is adapted to position the guide oppositethe intervertebral space between the upper vertebra and the lowervertebra and to adjust an angle formed by the insertion axis and anantero-posterior median sagittal axis defined by the intersection of amidline, substantially vertical, sagittal plane and a transverse,substantially horizontal, plane of the spinal column.

According to another feature in an embodiment, the angle adjustercomprises at least one sighting device configured for visual adjustmentof the angle between the insertion axis and the antero-posterior mediansagittal axis.

According to another feature in an embodiment, the angle adjustercomprises a sighting device configured for operation with at least onepin implanted into at least one of the upper vertebra and the lowervertebra and approximately oriented with the antero-posterior mediansagittal axis of said vertebra to align said sighting device with theantero-posterior median sagittal axis.

According to another feature in an embodiment, the instrumentationfurther comprises:

at least one pin for implantation into at least one of the uppervertebra and the lower vertebra in approximate orientation with theantero-posterior median sagittal axis of said vertebra;

at least one offset adjuster adjustably linking the angle adjuster tothe at least one pin.

According to another feature in an embodiment, the instrumentationfurther comprises:

at least one contact adjuster disposed approximately parallel to theinsertion axis;

a coupling between the at least one contact adjuster and the angleadjuster allowing movement of the angle adjuster with respect to the atleast one contact adjuster;

a connector configured to move along the longitudinal axis of the pinand to connect the at least one offset adjuster to the at least one pin.

According to another feature in an embodiment, the at least one pincomprises a sharp point.

According to another feature in an embodiment, the angle adjustercomprises at least one adjustment gauge indicating at least oneparameter concerning the position of the guide relative to thevertebrae.

According to another feature in an embodiment, the adjustment gaugecomprises a lateral offset gauge comprising a pointer pointing tograduations indicating the lateral offset of the guide from theantero-posterior median sagittal axis of the vertebrae.

According to another feature in an embodiment, the adjustment gaugecomprises an angle gauge comprising a pointer pointing to radialgraduations indicating the angle between the insertion axis of theintervertebral disc prosthesis and the antero-posterior median sagittalaxis of the vertebrae.

According to another feature in an embodiment, the instrumentationfurther comprises a tightener that selectively allows or preventsrotation of the angle adjuster with respect to the guide, therebypermitting adjustment and fixation of the angle between the insertionaxis of the intervertebral disc prosthesis and the antero-posteriormedian sagittal axis.

According to another feature in an embodiment, the at least one retainercomprises at least one groove permitting the at least one separator toslide within the groove.

According to another feature in an embodiment, the at least one retainercomprises at least one shaft providing at least one axis of rotation forthe at least one separator.

According to another feature in an embodiment, the guide furthercomprises a stop limiting the rotation of the at least one separatorabout the at least one axis of rotation.

According to another feature in an embodiment, the rotation of an atleast one separator is limited by an adjustable stop enabling to set theextent to which the rotation is limited.

According to another feature in an embodiment, the guide comprises atleast one channel oriented substantially parallel to the insertion axisof the intervertebral disc prosthesis and configured to guide at leastone part protruding from at least one surface of the intervertebral discprosthesis.

According to another feature in an embodiment, the insertion axis of theintervertebral disc prosthesis through the guide is orientedapproximately parallel to a longitudinal centerline of the guide passingthrough the open anterior and posterior faces of the cage.

According to another feature in an embodiment, the insertion axis of theintervertebral disc prosthesis through the guide is not orientedapproximately parallel to a longitudinal centerline of the guide passingthrough the open anterior and posterior faces of the cage.

According to another feature in an embodiment, the instrumentationfurther comprises at least one chisel having at least one blade andsuitable shape and dimension for engagement with the guide and forcutting at least one notch in a vertebra.

According to another feature in an embodiment, the chisel comprises ashaft, a handle at the end of the shaft opposite the at least one blade,and an adjustable stop limiting the travel of the chisel inside theguide.

According to another feature in an embodiment, the chisel comprises twoblades and a spacer of suitable dimension to separate the blades by adistance approximately equal to the height of the intervertebral space.

According to another feature in an embodiment, the instrumentationfurther comprises an impactor having a shaft, a handle at one end of theshaft for manipulating the impactor, and at the other end of the shaft apusher having shape and dimensions substantially conforming to at leastone edge of the intervertebral disc prosthesis contacted by the pusherduring use.

According to another feature in an embodiment, the impactor has anadjustable stop limiting the travel of the impactor inside the guide.

According to another feature in an embodiment, the instrumentationfurther comprises a holder for the intervertebral disc prosthesis andwherein the guide comprises a recess providing clearance for holder forthe intervertebral disc prosthesis sufficient to position theintervertebral disc prosthesis into the guide.

According to another feature in an embodiment, the instrumentationfurther comprises a holder for the guide engaging at least two notchesof the guide.

According to another feature in an embodiment, the holder for the guideis configured to engage the at least two notches of the guide withoutinterfering with engagement of a recess of the guide by tools foraccessing the intervertebral space or by the holder for theintervertebral disc prosthesis.

Methods for inserting intervertebral disc prostheses between twovertebrae are also provided.

General steps for preparing the vertebral site for insertion of anintervertebral disc prosthesis between two vertebrae are known, and arenot an aspect of the inventive method disclosed herein. In general, suchpreparatory steps comprise removal of the natural biologicalintervertebral disc, clearing the intervertebral space, and maintaininga gap between the upper vertebra and lower vertebra with a knowninstrument.

Methods for inserting an intervertebral disc prosthesis in accordancewith the present invention can be performed using instrumentationcomprising at least one pin and a guide having at least one upper plate,at least one lower plate, a cage defining an insertion axis for theintervertebral disc prosthesis and having open posterior and anteriorfaces, and an angle adjuster. In a preferred embodiment, a methodaccording the present invention comprises:

-   -   implanting at least one pin in the median sagittal axis of one        of the two vertebrae;    -   measuring the dimensions of the intervertebral space;    -   choosing the intervertebral disc prosthesis to be implanted;    -   choosing the guide to be used;    -   adjusting the angle adjuster based on an antero-posterior median        sagittal axis of the spinal column, defined by the intersection        of a midline, substantially vertical, sagittal plane and a        transverse, substantially horizontal, plane of the spinal        column, on the dimensions of the intervertebral space and on the        obstacles to access to the intervertebral space, in order to set        a desired angle between the insertion axis for the        intervertebral disc prosthesis and the antero-posterior median        sagittal axis;    -   positioning the guide adjacent to the intervertebral space at        the desired angle;    -   inserting the intervertebral disc prosthesis into the guide        through the open posterior face of the cage; and    -   inserting the intervertebral disc prosthesis into the        intervertebral space through the open anterior face of the cage.

According to another feature in an embodiment, the method furthercomprises a step of adjusting an offset adjuster for setting a lateraloffset of the guide relative to the antero-posterior median sagittalaxis.

According to another feature in an embodiment, the step of inserting theintervertebral disc prosthesis into the intervertebral space isperformed using an impactor comprising a shaft and an adjustable stop,said step further comprising adjustment of the stop and the applicationof a thrust to the impactor.

According to another feature in an embodiment, the step of adjusting theangle adjuster is performed using a sighting device for aligning theguide with the antero-posterior median sagittal axis, said step furthercomprising placement of the sighting device in contact with the at leastone pin.

According to another feature in an embodiment, the method furthercomprises a step of adjusting an offset adjuster of adjustable lengthconnecting the angle adjuster of the guide to a connector connected tothe pin, this adjusting step being implemented thanks to themeasurements of the intervertebral space.

According to another feature in an embodiment, the step of positioningthe guide adjacent to the intervertebral space further comprisestranslation of the guide along an axis substantially parallel to theantero-posterior median sagittal axis until the guide is proximal to thevertebrae.

According to another feature in an embodiment, the method furthercomprises the insertion of one or more separators into theintervertebral space.

According to another feature in an embodiment, the method furthercomprises the engagement of at least one of the one or more separatorswith at least one retainer of the guide.

According to another feature in an embodiment, the step of positioningthe guide is performed with a holder for the guide.

According to another feature in an embodiment, the step of inserting theintervertebral disc prosthesis into the guide is performed with a holderfor the intervertebral disc prosthesis, the guide comprising a recessproviding clearance sufficient for the holder for the intervertebraldisc prosthesis to position the intervertebral disc prosthesis into theguide.

According to another feature in an embodiment, the step of positioningthe guide is performed with a holder for the guide configured to engageat least two notches of the guide to provide clearance for tools foraccessing the intervertebral space.

According to another feature in an embodiment, the method furthercomprises, before inserting the intervertebral disc prosthesis into theintervertebral space, the step of preparing the intervertebral spaceusing a chisel having at least one blade, an adjustable stop andsuitable shape and dimension for engagement with the guide and forcutting at least one notch in at least one vertebra.

According to another feature in an embodiment, the method furthercomprises the step of clearing the intervertebral space of the bonedebris generated by cutting the notch.

According to another feature in an embodiment, the method furthercomprises a step of removing the guide, the one or more separators, andthe at least one pin after the step of inserting the intervertebral discintervertebral disc prosthesis into the intervertebral space.

Other features and advantages of the invention will become clearer uponreading the following description of various embodiments with referenceto the attached drawings.

BRIEF DESCRIPTION OF THE FIGURES

FIG. 1 represents a perspective view of the instrumentation according toan embodiment of the invention, with a pin implanted in a vertebra andthe guide facing the intervertebral space located above this vertebra.

FIG. 2 represents a top view of the instrumentation represented in FIG.1.

FIG. 3 represents a side view of the instrumentation in FIG. 1, seenfrom the posterior face of the guide.

FIGS. 4A and 4B represent, respectively, a perspective view and a topview of the guide according to an embodiment of the invention.

FIGS. 5A and 5B represent perspective views of another embodiment of theguide of the instrumentation, respectively, before and after theintroduction of the separating elements in the guide.

FIGS. 6A and 6B represent, respectively, a top view and a side view ofthe chisel according to an embodiment of the invention.

FIGS. 6C and 6D represent, respectively, a top view and a side view ofthe impactor on an embodiment of the invention.

FIGS. 7A and 7B represent a perspective view of an embodiment of theinvention, when using a chisel.

FIG. 7B presents further details of FIG. 7A.

FIGS. 8A and 8B represent a top view of the instrumentation according toan embodiment of the invention, when using the chisel and, respectively,before and after the penetration of the chisel into the vertebra.

FIG. 9A represents a perspective view of the instrumentation accordingto an embodiment of the invention, when using the impactor.

FIG. 9B presents further details of FIG. 9A.

FIG. 10A represents a top view of the instrumentation according to anembodiment of the invention, during the insertion of the prosthesis inthe guide.

FIG. 10B represents a top view of the instrumentation according to anembodiment of the invention, when using the impactor pushing theprosthesis inside the guide.

FIG. 11A represents a transparent view of the instrumentation accordingto an embodiment of the invention, when the prosthesis is being pushedinto the intervertebral space by the impactor according to an embodimentof the invention.

FIG. 11 b represents a prosthesis in place in the intervertebral spaceafter the impactor has been removed.

DESCRIPTION OF EMBODIMENTS

The invention relates to an instrumentation and methods for insertingintervertebral disc prostheses (P) between vertebrae (Vi, Vs). Theinvention complements general surgical instruments and methods. Thefollowing description presents different, non-restrictive, embodimentsof devices and methods according to various features of the invention.The different structures and steps in the various embodiments can beincorporated in the other embodiments in various combinations.

In a preferred embodiment, the instrumentation comprises a guide (1) inthe shape of an open cage that can slide, by use of a movable connector(22), on at least one pin (2) implanted into a vertebra. Two pins (2),one implanted in upper vertebra (Vs) and the other implanted in thelower vertebra (Vs), and two movable connectors (22), can also be used.

Various elements of the embodiments described herein involve anantero-posterior reference axis (S). The determination of thisantero-posterior reference axis will be apparent to the surgeon usingthe embodiments of the instrumentation and methods described. Ingeneral, the antero-posterior reference axis will lie along theintersection of a plane substantially coincident with a median sagittal(a substantially vertical plane along the midline of the spine) and aplane substantially coincident with a horizontal plane (a transverseplane, along the antero-posterior axis of the vertebrae andsubstantially horizontal), although other orientations may beappropriate depending on the particular characteristics of the spine andvertebrae and/or on the choice of the surgeon. For example, theantero-posterior reference axis (S) may not lie along the midlinesagittal plane of the spine and may thus be Para-Sagittal and it can beinclined leftward or rightward in the antero-posterior direction of thevertebrae. The antero-posterior reference axis (S) may also not bealigned along the horizontal plane of the vertebrae and may thus beinclined upward or downward in the antero-posterior direction of thevertebrae.

A holder (not represented) for the guide can be used to place the guide(1) over the pin (2) and to make it slide until it is proximal with thevertebrae. In a preferred embodiment, the guide (1) comprises twolateral faces, at least one upper plate (17) and at least one lowerplate (18) which together form a cage intended to receive the prosthesis(P) through its open posterior face and allow the insertion through itsopen anterior face of the prosthesis (P) between the lower (Vi) andupper (Vs) vertebrae. In use of the instrumentation, separators (10),comprising, for example, substantially rectangular plates havingdimensions adapted to the height of the prosthesis (P) (generallywithout regard to any osteal anchors), are placed approximately parallelto the lateral faces of the guide (1) and in proximity to the lateralfaces. Separators (10) maintain a sufficient gap between the vertebraeand, co-operating with the guide (1), allow the insertion of theprosthesis (P) between the vertebrae. A holder (not represented) of theprosthesis (P) allows placement of the prosthesis (P) inside the guide(1). An impactor (4) is provided for pushing the prosthesis (P) throughthe open cage of the guide into the intervertebral space.

Various embodiments of the invention will now further be described indetail in reference to the drawings. As shown in FIGS. 1 and 3, theguide (1) has a cage through which the prosthesis will be inserted untilit reaches the intervertebral space. The cage is open on its anteriorand posterior faces. The guide (1) comprises lateral faces, at least oneupper plate (17) and at least one lower plate (18). In the embodimentsrepresented in the drawings, the guide (1) has a shape substantially ofa parallelepiped, with its upper plate (17) and lower plate (18)approximately parallel to each other. In an alternative embodiment (notrepresented), the upper plate (17) and lower plate (18) are notapproximately parallel to each other and the guide (1) has, in coronal(frontal) section, a substantially trapezoidal shape. In thisalternative embodiment, the separators (10) could, according to theinsertion angle (A1) of the prosthesis (P), comprise non-rectangularplates such as trapezoidal plates, and/or could have differentdimensions from one lateral face of the guide (1) to the other. Atrapezoidal embodiment is especially suitable for implanting aprosthesis having upper and lower surfaces form an angle, thus imposingan inclination on the vertebrae between which they are intended to beimplanted.

In the embodiment represented in FIGS. 5A and 5B, the guide (1) hassolid lateral faces comprising substantially rectangular plates, whereasin the embodiments represented in the other figures, the lateral facesof the guide are open and comprise rods linking the upper plate (17) andlower plate (18). However, as mentioned above, the different structuresdescribed for the various embodiments of the instruments of theinvention can be adapted to other instruments and/or other embodiments.Thus, the guide (1) could have open lateral faces in the embodimentrepresented in FIGS. 5A and 5B or even have solid lateral faces in theembodiments represented in the other figures.

The guide (1) comprises, proximate to its lateral faces, retainer (100)allowing it to co-operate with separators (10) used to maintain a gapbetween the vertebrae before and during the insertion of the prosthesis.The separators (10) have a shape and dimensions adapted to the height ofthe prosthesis (P) (generally without regard to any osteal anchors),allowing for maintenance of a sufficient gap between the vertebrae (Vi,Vs) for the introduction of the prosthesis (P) into the intervertebralspace. The height of the cage of the guide (1) is adapted to the heightof the prosthesis (generally without regard to any osteal anchors).Guides of different heights generally will be used for prostheses ofdifferent heights. The width of the cage of the guide (1), however, canbe configured to allow the same guide to be used for the implanting ofprostheses of substantially different widths, as for the two prosthesesrepresented in FIGS. 11A and 11B. When a guide (1) is used forprostheses of substantially different widths, preferred embodiments useguiding channels (11) engaging osteal anchors on the prostheses to guidethe prostheses during insertion. A surgeon, however, will preferably usea guide (1) having a size most suitable to the dimensions of and theencumbrances of access to the intervertebral space, and will implant aprosthesis having a size most suitable to the dimensions of the guide(1) and the intervertebral space.

In the embodiments represented in FIGS. 5A and 5B, the retainer (100) ofthe guide (1) comprises grooves on each of the lateral edges of each ofthe lower (18) and upper (17) plates of the guide (1). The groovesreceive the separators (10), and permit the separators (10) toco-operate with the guide (1) by sliding in the grooves (100). Thesliding of the separators (10) in relation to these retainers (100)allows a translation of the guide (1) in relation to the separators(10). Thus, the separators (10) could be inserted between the vertebrae(Vs, Vi) before or after the positioning of the guide (1). For example,this embodiment also allows to remove the guide (1) once the prosthesishas been implanted, while leaving the separators (10) in place betweenthe vertebrae (Vs, Vi) to allow proper positioning of the prosthesis.

In the embodiments represented in FIGS. 1 to 4 and 7 to 11, the retainer(100) of the guide comprises shafts located proximally to the lateralfaces of the guide (1). These shafts provide axes of rotation aboutwhich the separators (10) may rotate. In these embodiments of retainer(100), as seen in FIGS. 1 and 2 stops limiting the rotation can bedisposed proximal to the lateral faces, towards the exterior of theguide, limiting rotation of the separators (10) about their respectiveaxis of rotation (100). In a preferred embodiment, these stops comprisea rod (13 a) having a distance to the anterior face of the guide (1)that is less than the distance of the axis of rotation (100) of theseparators (10) to the anterior face of the guide (1). In anotherembodiment, the stops are adjustable and comprise, for example, at leastone conical part (13 b) screwed into at least the upper (17) or lower(18) plates of the guide. The depth of the adjustable stop can be setusing the screw threads, and will adjust the limit on the rotation ofthe separators (10) about their axis of rotation (100). The stopslimiting the rotation of the separators (10) about their axis ofrotation can also comprise, as in the embodiment represented in FIGS. 4Aand 4B, studs (13 a) attached to the separators (10) and projecting intoan opening or recess made in at least one of the lower plate (18) andupper plate (17). In this embodiment of stops (13 a), the relative sizesof these studs and the opening or recess can be used to establish thelimit on the rotational freedom of the separators (10).

In a preferred embodiment, instrumentation according to the inventioncomprises at least a pin (2) having a sharp point (21) intended to beimplanted into an antero-posterior reference axis (S) of one of thevertebrae (Vi, Vs) between which the prosthesis (P) is to be implanted.Implanting the pin (2) into a vertebra provides a reference that, inconjunction with other structure of the guide (1), permits targeting thepoint (C) onto which the prosthesis (P) is to be centred in theintervertebral space. The guide (1) comprises at least one angleadjuster (12) allowing adjustment of the insertion axis (X) of theprosthesis (P) in relation to the antero-posterior reference axis (S) ofthe vertebrae, and thus the angle (A1) between the insertion axis (X)and the antero-posterior reference axis (S). The intersection betweenthe insertion axis (X) and the antero-posterior reference axis (S)defines a point which can be set to coincide with the point (C) ontowhich the prosthesis (P) is to be centred in the intervertebral space.The antero-posterior reference axis (S) may lie along the intersectionof a plane substantially coincident with a median sagittal plane and aplane substantially coincident with a horizontal plane, although otherorientations may be appropriate depending on the particularcharacteristics of the spine and vertebrae and/or depending on thechoice of the surgeon.

In the embodiments represented in FIGS. 4A, 4B, 5A and 5B, the angleadjuster (12) comprises a sighting device having, for instance, a backsight intended to cooperate with at least one pin (2) implanted in themedian sagittal axis of at least one vertebra. The back sight preferablyhas a suitable shape and dimension to cooperate with the pin (2) toallow the back sight to be placed against the pin and to slide the guide(1) along the pin, thereby permitting a suitable positioning of theguide (1) along the antero-posterior reference axis (S). By providingstable placement of the guide (1) with reference to the antero-posteriorreference axis (S), the sighting device (12) also facilitates adjustment(either visually or by use of a gauge or other device) of the angle (A1)between the insertion axis (X) of the prosthesis (P) and theantero-posterior reference axis (S) of the vertebrae (Vi, Vs).

In the embodiments represented in FIGS. 1 to 3 and 7 to 11, an offsetadjuster (120) of adjustable length links the angle adjuster (12) to aconnector (22) that can slide on pin (2). For one embodiment, the offsetadjuster (120) comprises a rod with one end fixed to the connector (22)and the opposite end threaded to mate with a treaded hole in the angleadjuster (12). In another of the various alternative embodiments, theoffset adjuster (120) comprises a rod attached to connector (22) butfreely rotatable with respect to connector (22). In such alternativeembodiment, offset adjuster (120) can be screwed in the threaded hole inangle adjuster (12) even when connector (22) is in place on pin (2). Forexample, a six-sided hole can be formed in the threaded end of offsetadjuster (120) and used to rotate offset adjuster (120) with knowntools.

The guide (1) can also comprise at least one contact adjuster (110). Invarious embodiments of contact adjusters (110), the contact adjuster(110) is disposed approximately parallel to the insertion axis (X) ofthe prosthesis (P). The angle adjuster (12) is configured to slide alongthe contact adjuster (110), although other adjustable couplings betweenthe angle adjuster (12) and the contact adjuster (110) are readilyapparent. In this arrangement, angle adjuster (12) can be set to thedesired angle (A1) between the insertion axis (X) of the prosthesis (P)and the antero-posterior reference axis (S), and by adjusting thedistance between angle adjuster (12) and connector (22) using offsetadjuster (120), the intersection point between the insertion axis (X) ofthe prosthesis (P) and the antero-posterior reference axis (S) of thevertebrae can be made to coincide with the point (C) on which theprosthesis (P) is to be centered. By moving the angle adjuster (12)along the contact adjuster (110), the guide (1) can be brought proximalto the vertebrae (Vi, Vs) while maintaining the connector (22) in thedesired proximity to the adjacent vertebra.

In various embodiments, the angle adjuster (12) of the guide (1)comprises an adjustment gauge. The adjustment gauge can be configured toindicate one or more adjustment of the guide (1), including, forexample, the angle (A1) between the insertion axis (X) of the prosthesis(P) and the antero-posterior reference axis (S) and/or the length of theoffset distance between angle adjuster (12) and connector (22).

The adjustment gauge embodiment illustrated in FIG. 2 comprises alateral offset gauge. In this embodiment, the lateral offset gaugeindicates the length of the offset distance between angle adjuster (12)and connector (22), indirectly measuring the offset of the guide (1)laterally from the antero-posterior reference axis (S). The lateraloffset gauge comprises a pointer (121 ₁) attached to the angle adjuster(12) and located proximal to graduations (121 ₂) made in a surface ofthe offset adjuster (120). The position of the pointer (121 ₁) inrelation to the graduations (121 ₂) indicates the length of the offsetdistance between angle adjuster (12) and connector (22) and thereforethe lateral offset of the guide (1) in relation to the pin (2).

The adjustment gauge embodiment illustrated in FIG. 2 further comprisesan angle gauge indicating the angle (A1) between the insertion axis (X)of the prosthesis (P) and the antero-posterior reference axis (S). Inthis embodiment, the angle gauge comprises a pointer (122 ₁) attached tothe angle adjuster (12) and located proximal to radial graduations (122₂) made in the surface of the guide (1). The position of the pointer(122 ₁) in relation to the graduations (122 ₂) indicates the angle (A1)along which the prosthesis (P) will be implanted in relation to theantero-posterior reference axis (S) of the vertebrae (Vs, Vi).

In an alternative embodiment, a tightener is provided that selectivelyallows or prevents rotation of the angle adjuster (12) with respect tothe cage of the guide (1). The tightener permits adjustment of the angle(A1) between the insertion axis (X) of the prosthesis (P) and theantero-posterior reference axis (S) by allowing rotation of the angleadjuster (12), and permits fixation of that angle (A1) in properadjustment by preventing rotation of the angle adjuster (12).

In the disclosed embodiments, the pin (2) is intended to be implanted ina horizontal transverse plane of the vertebrae. Two pins (2) can also beused, along with two angle adjuster (12), for example, placed one on oneof the upper plate (17) and one on the lower plate (18) as shown in FIG.3. However, the instrumentation also may use a pin (2) to be implantedother than in a horizontal transverse plane of the vertebrae. Forexample, the pin (2) may be implanted in an inclined manner in thesagittal plane with its point (21) oriented towards the bottom of thespinal column. In that configuration, the guide (1) could be providedwith a single angle adjuster (12) on one of the upper plate (1.7) orlower plate (18), but still be held in the suitable horizontal positionby using to the adjustable offset adjuster (120) and the angle adjuster(12).

Some prostheses have osteal anchors (51) on the surfaces that contactadjacent vertebrae. For example, winglets on the prosthesis can beprovided to engage notches made in the surfaces of the vertebrae. Thesurfaces of the vertebrae engaged by the osteal anchors (51) of thistype of prosthesis therefore must be prepared before insertion of theprosthesis. Accordingly, in a preferred embodiment the instrumentationcomprises a chisel (3) used to prepare intervertebral space. The chisel(3) has suitable shape and dimension to penetrate into the open cage ofthe guide (1) and pass through the guide (1) to make cuttings on thevertebrae that will be engaged by an osteal anchor (51). In a preferredembodiment, at least one plate among the upper (17) and lower (18)plates of the guide (1) comprises a guiding channel (11) oriented alongthe insertion axis (X) of the prosthesis (P). This guiding channel (11)has a shape and dimensions adapted to the shape and dimensions of anosteal anchor (51) of the prosthesis (P). The notch made in the vertebrausing the chisel (3) assists centering of the prosthesis in relation tothe point (C). In the embodiments represented in the drawings, theguiding channel (11) defining the insertion axis (X) of the prosthesisis not approximately parallel to the longitudinal centerline (L) passingthrough the anterior and posterior open faces of the guide (1), but theguiding channel (11) can obviously be made so as to define an insertionaxis (X) of the prosthesis approximately parallel to the longitudinalcenterline passing through the anterior and posterior faces of the guide(1).

In a preferred embodiment, the chisel (3) comprises a shaft (30) having,at one of its ends, at least one blade (32) of suitable shape anddimension for engagement with the guiding channel (11) of the guide (1)and for cutting a notch in a vertebra complementary with the shape anddimension of an osteal anchor (51). The shaft has, at its other end, ahandle (35) allowing positioning of the blade (32) into the guidingchannel (11) manipulating of the chisel to make a notch in the vertebrafor the osteal anchor (51) of the prosthesis (P). An adjustable stop(31) on the shaft (30) can limit the travel of the chisel (3) in theaxis (X) of the guide (1) and therefore limit the length of the notch,which can correspond to length of the osteal anchor (51). In theembodiment in FIGS. 6A and 6B, the chisel (3) comprises two blades (32)held apart from each other by a spacer (33) of suitable dimension toseparate the blades (32) by a distance approximately equal to the heightof the intervertebral disc prosthesis (P) (generally without regard toany osteal anchors). Using two guiding channels (11), the chisel (3) canbe used to simultaneously form two notches of suitable dimensions andpositions to receive the osteal anchors (51) assembled on the upper andlower surfaces of the prosthesis (P).

In an embodiment of the invention, the instrumentation comprises animpactor (4) as shown in FIGS. 6C and 6D used to move the prosthesis (P)through the cage of the guide (1) into the intervertebral space. Theimpactor (4) comprises a shaft (40), a handle (45) at one end of theshaft for manipulating the impactor, and at the other end of the shaft apusher (42) having shape and dimensions substantially conforming to theedges of the intervertebral disc prosthesis (P) contacted by the pusher(42) during use. The height and width of the pusher (42) can besubstantially equal, respectively, to the height (generally withoutregard to any osteal anchors) and the width of the prosthesis (P). Anadjustable stop (41) on the shaft (40) of the impactor (4) can limit thetravel of the impactor (4) in the insertion axis (X) of the prosthesis(P) and therefore control the depth to which the prosthesis (P) will beinserted into the intervertebral space. The stop (41) therefore canassist centering the prosthesis (P) in relation to the point (C).

In an embodiment of the invention, the instrumentation can comprise aholder (not shown) for the prosthesis (P). As shown in the drawings, atleast one of the upper plate (17) and the lower plate (18) comprises arecess (111) providing clearance of the holder for the prosthesis (P)and allowing the prosthesis (P) to be placed in the guide (1) with theholder. Such holder for the prosthesis (P) may consist, for example, offorceps or pliers or tweezers of a known type, with shape and dimensionsadapted to insert the prosthesis (P) in the guide (1) by engaging therecess (111).

In an embodiment of the invention, the instrumentation can comprise aholder (not shown) for the guide (1). The holder can assist positioningthe guide (1) in suitable position in contact with the vertebrae (Vi,Vs). The holder co-operates with at least two notches (112) made on atleast one of the upper plate (17) and the lower plate (18). Asrepresented in drawings, the notches (112) are located in the recess(111) of the guide (1). Such holder for the guide (1) may consist, forexample, of dilating forceps or opening pliers, or opening tweezers of aknown type, with shape and dimensions adapted to co-operate with thenotches (112) while leaving the recess (111) accessible to forceps orpliers or suitable tools for accessing the intervertebral space. Forexample, the holder for the guide (1) may consist of opening pliershaving opening ends curved in a direction approximately orthogonal tothe direction of the opening of the pliers. These curved ends thusco-operate with the notches (112) in the recess (111) and may havedimensions adapted so that, when they co-operate with the notches (112),they do not substantially protrude from the notches (112) inside therecess (111). Such holder will thus hold the guide (1) while leaving arecess (111) accessible for the clearance of pliers or small tweezers orany suitable tools for accessing the intervertebral space through theguide (1). The recess (111) may also be accessible for the clearance ofthe holder for the prosthesis (P) and for the positioning of theprosthesis (P) into the guide (1), if the holder has still not beenremoved at this step.

The various embodiments of the invention described above provideinstrumentation for implanting an intervertebral disc prosthesis (P)between the vertebrae (Vs, Vi). The use of the instrumentation will nowbe described, providing detail of the steps taken to implant theprosthesis.

As aforementioned, the invention compliments general surgicalinstruments and methods, which are not an aspect of the inventive methoddisclosed herein and will not be described. In addition, theprerequisite steps for preparing the patient and access to thevertebrae, for example from the anterior face, will not be described indetail. Prior to the implanting itself of the prosthesis (P), thesurgeon creates an access to the vertebrae and removes thefibro-cartilaginous tissue of the natural biological intervertebraldisc. Generally, separators (tweezers, according to a commonly useddesignation) of a known type maintain a gap between the vertebrae duringthe removal of the natural biological disc by the surgeon. The naturalgap of the vertebrae will have been measured beforehand to determine theheight (generally without regard to any osteal anchors) of theprosthesis (P) to be implanted in the intervertebral space and,consequently, the height of the guide (1) that is to be chosen forimplantation. Measuring the height of the intervertebral space alsoallows determination of the height of the separators (10), which ischosen to maintain the gap required for inserting the prosthesis (P)between the vertebrae. The guide (1) will thus be chosen according tothe height of these separators (10) and the dimensions of the prosthesis(P) in the horizontal plane, which will depend on the dimensions of thevertebrae and the encumbrances to accessing the intervertebral space.

During the removal of the natural biological disc by the surgeon,separators (tweezers) commonly used are too cumbersome for the rest ofthe operation and are thus replaced by a wedge (called “spacer” or“bougie”, according to a commonly used designation in English or French,respectively) whose height will have been chosen so as to preserve thenatural gap of the vertebrae and to correspond to the height of theprosthesis (P) (generally without regard to any osteal anchors).

The removal of the natural biological intervertebral disc can bepreceded or followed by a step of implanting at least one pin (2) of theinstrumentation in at least one of the vertebrae (Vi, Vs) between whichthe prosthesis is to be implanted. So that the pin (2) provides asymmetrical reference in relation to the vertebrae, the implanting ofthe pin (2) is performed by placing it, preferably horizontally, alongthe antero-posterior reference axis (S) of the vertebra. The dimensionsof the guide (1) chosen for implanting the prosthesis will affect theheight in the vertebra for implantation of pin (2), which should enablethe angle adjuster (12) to place the guide (1) opposite theintervertebral space with its upper plate (17) and lower plate (18) incontact with the respectively upper and lower surfaces of therespectively upper and lower vertebrae. In a known manner, the surgeonmeasures the exact dimensions of the vertebrae, using a known measuringdevice. The measuring of the vertebrae, notably along theantero-posterior axis, informs the surgeon of the depth of theintervertebral space and allows the surgeon to determine the idealdimensions of the prosthesis (P) in the horizontal plane and tocalculate, as a function of the dimensions of the measured vertebrae andof the chosen prosthesis, the position of the point (C) on which theprosthesis (P) is to be centered. By taking a radiograph of the vertebrain which the pin (2) was implanted, for example using a known imageintensifier, the surgeon can also control the proper positioning of thepoint (21) of the pin in the vertebra, for example its alignment on themedian sagittal axis. The pins (2) are short and comprise, for example,small diameter rods. The small dimensions of the pins allow the surgeonto possibly recommence the step of implanting the pin (2) into thevertebra if he considers that the position of the point (21) isunsatisfactory.

Once these measurements have been made, the surgeon has all theinformation necessary to choose the most appropriate guide (1) andprosthesis (P). According to the embodiment of the guide (1) chosen bythe surgeon, the surgeon adjusts, according to the gatheredmeasurements, the angle adjuster (12) to accurately target the point (C)on which the prosthesis (P) is to be centered in the intervertebralspace.

The positioning of the guide (1) opposite the intervertebral space canbe performed using a holder for the guide or without the use of such aholder. Among other embodiments of the invention, the surgeon can choosebetween separators (10) that slide in the grooves of the retainer (100)or separators (10) that rotate about their axes of rotation on shafts(100). For separators (10) that slide in the grooves of the retainer(100), the surgeon inserts separators (10) in the intervertebral space,removes the known wedge (bougie or spacer), and slides the guide (1) onthe separators (10) to bring the guide (1) proximal to the vertebrae.For separators (10) that rotate about their axes of rotation on shafts(100), the surgeon inserts the separators (10) assembled on shafts(100), removes the known wedge (bougie or spacer), and drives theseparators (10) into the intervertebral space until the guide isproximal with the vertebrae.

The surgeon may choose different embodiments of the angle adjuster (12)to more readily facilitate placement of the prosthesis (P) centered atpoint (C). According to the encumbrance of the surgeon's access to thevertebrae, the surgeon will choose one of the embodiments describedbelow so as to insert the prosthesis along the antero-posterior sagittalaxis or along an inclined axis.

In the embodiment of the instrument described above in which the angleadjuster (12) comprise a sighting device created by a back sight, andpreferably in the case where the prosthesis can be implanted straight onand does not require an oblique insertion, the surgeon targets the point(C) by placing the sighting device in the median sagittal axis of thevertebrae marked by at least one pin (2) implanted in at least onevertebra. The back sight preferably has a suitable shape and dimensionto co-operate with the pin (2), so as to allow the back sight to beplaced against the pin and to slide the guide (1) along the pin, therebyensuring suitable positioning of the guide in relation to the vertebrae.The surgeon inserts the prosthesis (P) it into the cage of the guide (1)though the cage's open posterior face. A holder for the prosthesis canbe used that allows, as mentioned above, insertion of the prosthesis (P)into the cage of the guide while the holder for the guide is still inits place and holding the guide in contact with the vertebrae. Theimpactor (4) allows the surgeon to implant the prosthesis between thevertebrae by pushing on the handle (45) of the impactor (4) or byhitting, for example with a hammer, on this handle (45). The adjustableposition of the stop (41) on the shaft (40) of the impactor (4) willhave already been set according to the distance of point (C) on whichthe prosthesis is to be centred between the vertebrae, in relation tothe anterior face of the vertebrae. The adjusting of the position of thestop naturally takes into account the size of the pusher (42) of theimpactor (4) and the diameter of the prosthesis (P).

According to the vertebrae (Vi, Vs) between which the prosthesis (P) isto be implanted, implanting of the prosthesis (P) along theantero-posterior sagittal axis may not necessarily be the easiest orleast risky solution. For example, the vena cava and the aorta, whichare major life-supporting blood vessels, pass in front of the lumbarvertebrae and considerably encumber the access to the anterior face ofsuch vertebrae. The surgeon may therefore prefer to implant theintervertebral disc prosthesis (P) along an oblique axis of insertion,such as an antero-lateral axis in the case of access to the vertebraefrom the anterior face. Some of the embodiments of the inventionfacilitate insertion of the prosthesis (P) obliquely, for example, byuse of an angle adjuster (12) to set an angle (A1) between the insertionaxis (X) of the prosthesis and the antero-posterior reference axis (S).

The small diameter pins (2) can be implanted in the median sagittalplane of the vertebrae without having to shift to any great extent thetissue and/or the organs passing over the anterior face of thevertebrae. The angle (A1) created between the insertion axis (X) of theprosthesis and the antero-posterior reference axis (S), as well as themagnitude of the offset of the guide (1) on one side of the vertebrae,will already have been determined according to the encumbrances toaccess to the vertebrae (Vi, Vs), the size of the vertebrae (Vi, Vs),and the size of the prosthesis (P). Thus, adjusting the angle (A1) andthe offset of guide (1) from the antero-posterior reference axis (S)permits the intersection the axis of insertion (X) and of theantero-posterior reference axis (S) to coincide with the point (C) onwhich the prosthesis is to be centred.

Offset adjuster (120) can be used to establish the offset of guide (1)from the antero-posterior reference axis (S), for example, by screwingto a greater or lesser degree a threaded end of offset adjuster (120)into a threaded hole made in the angle adjuster (12). As mentionedabove, adjustment of the length of the offset adjuster (120) can beperformed before or after the connector (22) is placed on the pin (2),depending on the chosen embodiment. The sliding of the connector (22)over the pin (2) allows the guide (1) to be brought proximal to thevertebrae, with its anterior face opposite the intervertebral space.Other steps for implanting can be identical to those previouslydescribed, for example by using the impactor (4) of which the positionof the stop (41) on the shaft (40) of the impactor (4) will already havebeen set according to the distance of the point (C) in relation to theanterior face of the vertebrae and according to the size of theprosthesis (P).

If the prosthesis comprises osteal anchors (51) fixed to the surfaces ofthe prosthesis (P), the chisel (3) is used to make notches in thevertebrae of shape and dimension complementary with the shape anddimension of the osteal anchors (51). The handle (35) of the chisel (3)can be used to push, or perhaps use strikes of a hammer, and pull thechisel (3) to make such notches. As mentioned above, the shape anddimension of the different embodiments of the chisel (3) are adapted tothe type of prosthesis (P) to be implanted and to the type of ostealanchors (51). After preparing the intervertebral space with the chisel(3), the surgeon removes the chisel (3) from the inside of the guide (1)and removes the fragments of bone generated by making the notches. Theprosthesis is implanted between the vertebrae using the impactor (4).

Once the prosthesis has been properly placed in the intervertebralspace, the surgeon removes the guide (1), the separators (10) and thepin(s) (2).

Although the present invention has been described in detail, it will beapparent to those skilled in the art that many embodiments taking avariety of specific forms and reflecting changes, substitutions andalterations can be made without departing from the spirit and scope ofthe invention. Therefore, the described embodiments illustrate but donot restrict the scope of the claims.

The invention claimed is:
 1. Instrumentation comprising a guide forinserting an intervertebral disc prosthesis having a height into anintervertebral space between an upper vertebra and a lower vertebra, theguide comprising: a connector generally aligned with an antero-posteriorreference axis of the instrument; a cage defining an insertion axis forthe intervertebral disc prosthesis and having open posterior andanterior faces, and comprising at least two lateral faces, at least oneupper plate, at least one lower plate separated from the at least oneupper plate by a distance at least equal to the height of theintervertebral disc prosthesis, and an angle adjuster adapted toposition the guide opposite the intervertebral space and to adjust anangle formed by the insertion axis and the antero-posterior referenceaxis.
 2. Instrumentation according to claim 1, further comprising atleast one separator sized to maintain a gap between the upper vertebraand the lower vertebra, which gap is sufficient for insertion of theintervertebral disc prosthesis through the guide into an intervertebralspace between the upper vertebra and the lower vertebra. 3.Instrumentation according to claim 2, further comprising at least oneretainer maintaining the at least one separator in position relative tothe guide.
 4. Instrumentation according to claim 3, in which the atleast one retainer comprises at least one groove permitting the at leastone separator to slide within the groove.
 5. Instrumentation accordingto claim 3, in which the at least one retainer comprises at least oneshaft providing at least one axis of rotation for the at least oneseparator.
 6. Instrumentation according to claim 5, in which the guidefurther comprises a stop limiting the rotation of the at least oneseparator about the at least one axis of rotation.
 7. Instrumentationaccording to claim 5, in which the rotation of an at least one separatoris limited by an adjustable stop enabling to set the extent to which therotation is limited.
 8. Instrumentation according to claims 1, in whichthe angle adjuster comprises at least one sighting device configured forvisual adjustment of the angle between the insertion axis and theantero-posterior reference axis.
 9. Instrumentation according to claim1, in which the the angle adjuster comprises a sighting deviceconfigured for operation with at least one pin implanted into at leastone of the upper vertebra and the lower vertebra and approximatelyoriented with the antero-posterior reference axis to align said sightingdevice with the antero-posterior reference axis.
 10. Instrumentationaccording to claim 1, further comprising: at least one pin forimplantation into at least one of the upper vertebra and the lowervertebra in approximate orientation with the antero-posterior referenceaxis; and at least one offset adjuster adjustably linking the angleadjuster to the at least one pin.
 11. Instrumentation according to claim10 in which the connector is configured to move along a longitudinalaxis of the pin and to connect the at least one offset adjuster to theat least one pin, further comprising: at least one contact adjusterdisposed approximately parallel to the insertion axis; a couplingbetween the at least one contact adjuster and the angle adjusterallowing movement of the angle adjuster with respect to the at least onecontact adjuster.
 12. Instrumentation according to claim 11, in whichthe least one pin comprises a sharp point.
 13. Instrumentation accordingto claim 1, in which the angle adjuster comprises at least oneadjustment gauge indicating at least one parameter concerning theposition of the guide relative to the vertebrae.
 14. Instrumentationaccording to claim 13, in which the adjustment gauge comprises a lateraloffset gauge comprising a pointer pointing to graduations indicating thelateral offset of the guide from the antero-posterior reference axis.15. Instrumentation according to claim 14, in which the adjustment gaugecomprises an angle gauge comprising a pointer pointing to radialgraduations indicating the angle between the insertion axis and theantero-posterior reference axis.
 16. Instrumentation according to claim1, further comprising a tightener that selectively allows or preventsrotation of the angle adjuster with respect to the guide, therebypermitting adjustment and fixation of the angle between the insertionaxis of the intervertebral disc prosthesis and the antero-posteriorreference axis.
 17. Instrumentation according to one of the precedingclaims, characterized in that the guide comprises at least one channeloriented substantially parallel to the insertion axis of theintervertebral disc prosthesis and configured to guide at least one partprotruding from at least one surface of the intervertebral discprosthesis.
 18. Instrumentation according to claim 1, in which theinsertion axis of the intervertebral disc prosthesis through the guideis oriented approximately parallel to a longitudinal centerline of theguide passing through the open anterior and posterior faces of the cage.19. Instrumentation according to claim 1, in which the insertion axis ofthe intervertebral disc prosthesis through the guide is not orientedapproximately parallel to a longitudinal centerline of the guide passingthrough the open anterior and posterior faces of the cage. 20.Instrumentation according to claim 1, further comprising at least onechisel having at least one blade and suitable shape and dimension forengagement with the guide and for cutting at least one notch in avertebra.
 21. Instrumentation according to claim 20, in which the chiselcomprises a shaft, a handle at the end of the shaft opposite the atleast one blade, and an adjustable stop limiting the travel of thechisel inside the guide.
 22. Instrumentation according to claim 20, inwhich the chisel comprises two blades and a spacer of suitable dimensionto separate the blades by a distance approximately equal to the heightof the intervertebral space.
 23. Instrumentation according to claim 1,further comprising an impactor having a shaft, a handle at one end ofthe shaft for manipulating the impactor, and at the other end of theshaft a pusher having shape and dimensions substantially conforming toat least one edge of the intervertebral disc prosthesis contacted by thepusher during use.
 24. Instrumentation according to claim 23, in whichthe impactor has an adjustable stop limiting the travel of the impactorinside the guide.
 25. Instrumentation according to claim 1, furthercomprising a holder for the intervertebral disc prosthesis, and theguide comprises a recess providing clearance for holder for theintervertebral disc prosthesis sufficient to position the intervertebraldisc prosthesis into the guide.
 26. Instrumentation according to claim1, further comprising a holder for the guide engaging at least twonotches of the guide.
 27. Instrumentation according to claim 26, inwhich the holder for the guide is configured to engage the at least twonotches of the guide without interfering with engagement of a recess ofthe guide by tools for accessing the intervertebral space or by theholder for the intervertebral disc prosthesis.